Provider Demographics
NPI:1245553635
Name:JACKSON, ROBIN LASHAWN (NP-C)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:LASHAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:LASHAWN
Other - Last Name:PARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:1500 WEISS ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5251
Mailing Address - Country:US
Mailing Address - Phone:989-497-2500
Mailing Address - Fax:
Practice Address - Street 1:1500 WEISS ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5251
Practice Address - Country:US
Practice Address - Phone:989-497-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704233306363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245553635Medicaid
MIP11290015Medicare PIN